On the Receiving End

2008
Bardai, Zahra

The woman tried to wait patiently. It had already been an hour. Her heart was hammering, her pupils slightly dilated, her breathing shallow. She tried to separate her anxiety from what she knew to be true. Her child was not in mortal danger. Yet looking into his fever glazed eyes and unnaturally red cheeks, she couldn't keep her breath from catching in her throat. He was not yet a year old and he'd had a fever for the last five days that just wouldn’t break. Acetaminophen and ibuprofen at maximum doses could not bring down his temperature. She thought with disbelief, ‘How could he continue to have a rectal temperature of 39.4 degrees Celsius, when he had been given both medications in the last three hours?' Their effects should have kicked in by now. He lay whimpering in her arms. He had barely had anything to eat, and his fluid intake had been minimal at best. The checklist for dehydration beat a staccato rhythm in her head; a dry diaper for nearly 24 hours, weight loss of more than 10%, crying with no tears for hours, increase in irritability, significant decrease in fluid intake, reduction in activity level... the steady tattoo was suddenly interrupted by her child's name being called out. Finally it was their turn to see the doctor.

They'd been seen by someone replacing their family doctor only two days ago, "It's probably viral and nothing to be concerned about" they had been told. She had accepted the diagnosis, and had been relieved. The slight redness that had been found in his ears and throat would resolve on its own. It would only be a matter of time before her infant son would be babbling and cooing to her again.

A very long 48 hours later and he remained mostly silent. While under the influence of rotating antipyretic dosing, he would perk up a bit, but he continued to remain clingy and disinterested in feeding. His temperature never really returned to an afebrile state. She was very concerned about the possibility of a febrile seizure. She had really tried hard not to doctor to him herself, but she had finally reached her breaking point and examined him ... could his ears be considered abnormally red and injected? How about his throat? Was that exudate on the back of his pharynx? Surely what she was feeling was a chain of reactive lymph nodes? The locum physician had given her a prescription for antibiotics with instructions on starting treatment if her son's condition deteriorated, didn't improve in 1-2 days or if the throat swab results were positive.

The laboratory results were not yet available and her little one's condition had certainly not improved. She ignored the whispering of her conscience that a focus of infection wasn't inherently obvious. Another checklist inadvertently went up in her head: no cough, no runny nose, no congestion, no discernable otalgia or urinary symptoms, no infected wounds. Yet, she convinced herself that some soft signs of bacterial infection were present and so the initiation of an antibiotic was justified. At least it meant that she would be doing more than just passively watching her son suffer.. . The decision was made. She would start the antibiotics, await results and call for a pediatric consultation.

That brought her to this moment, waiting for the pediatrician to assess her son's fever.

Once again, her son’s name was called. She hastily collected their things, and made her way to the exam room. The doctor came in calm and collected, transmitting a confidence born of years of experience. She knew him professionally and trusted his judgment. She repeated the story of their lives in the last few days. She waited while he examined her son, trying to conceal her nervousness.

"Benign viral fever, probably roseola," was his diagnosis. "Stop the antibiotics," was his decree.

"But what of his prolonged fever? I've only seen them last three to four days with roseola," she said.

"Well I've seen these fevers last a week or more. In fact I have an outpatient right now with a high fever for 20 days that I reassess every 3 to 4 days," he replied.

Feeling rebuffed she tried again.

"Am I missing a hidden focus? And how about the dehydration?" she asked in a rush, not wanting to forget anything.

"Probably not. It's rare for a strep pharyngitis at this age so his throat swab will likely be negative. Since it hasn't been done yet, we can do a urine analysis. However, given the likelihood of a community acquired UTI being caused by antibiotic sensitive E. Coli and the fact that a few doses of antibiotics have already been used, if it is a urinary tract infection, the dip and culture will most likely be negative.'

She sensed the unspoken disapproval of her decision in his voice.

"What's my threshold to worry. he's got to be 5-10% dehydrated by now," she said. Err, more like 3-5%. He's not like my other dehydrated kids and we don't want to over investigate him. Don't worry, before you can blink the fever will be gone and you'll see the telltale rash," he said as he left the room.

She caught up with him in the hallway, another burning question bubbling up, "What about fever control?"

He launched into a soliloquy about current guidelines, recommendations and commentary on the use of fever controlling agents and then turned away to chart, summarily dismissing her.

True to the doctor's prediction, the fever lasted a total of a week and was followed by a rash. Her son's spirits lifted and he recovered without incident. In hindsight she acquiesced to his pediatrician's knowledge, judgment and experience even though the interaction had left her feeling unsatisfied and invalidated.

The greater lesson learned from the encounter was a deep and abiding recognition of the profound emotional reservoir of fear and helplessness driving patient (and parental) responses to illness. She made herself two promises. The first vow was to acknowledge the risk of her own bias, especially in dealing with illnesses in her family. The second one was to respond to each of her own patients in a manner where they would feel heard, and their concerns substantiated while continuing to do her best to practice with the highest standard of care.